Industry Voices—Health plans paying price for unaddressed behavioral health needs

Two people in a therapy session
For the U.S. healthcare system, the health plans that cover these members, and individuals, the consequences of not participating in care can be dire. (Getty/shironosov)

Despite having access to health insurance, many Americans avoid seeking medical care. Further, lack of participation often is worse among people experiencing behavioral health issues such as anxiety and depression, both of which are significantly on the rise amid the COVID-19 pandemic.  

For the U.S. healthcare system, the health plans that cover these members, and individuals, the consequences of not participating in care can be dire. For individuals and their families, foregoing needed care may result in late detection or treatment of disease, reduced survival, increased costs, and potentially preventable human suffering.

For health plans, members’ lack of engagement can lead to untreated chronic conditions growing worse over time, potentially adding between $100 billion to $140 billion dollars in additional behavioral and physical health spending between 2020 and 2021, according to a recent analysis by McKinsey and Company.

People with unmanaged behavioral health conditions may represent a small segment of the population but drive much of the costs.

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According to a recent Milliman Research Report, out of a population of 21 million insured individuals, individuals with both behavioral health conditions and high medical costs constituted 5.7% (1.2 million) but accounted for 44% of overall healthcare costs. However, half of those individuals had less than $95 per year of total spending for behavioral health treatment.

Of the total healthcare costs for the entire study population, only 4.4% were for behavioral health treatment, underscoring the need to better engage this vulnerable and unaddressed population.

While the reasons that so many Americans do not participate in the healthcare system are varied and complex, the opportunity to better serve these individuals is significant and entirely within reach. But payers typically have struggled to do this for varied reasons, including that it is difficult to engage members and keep them in treatment long enough to achieve meaningful behavior change.

A successful strategy will begin by identifying high-cost members that can be impacted and then use a whole-person approach to engage and help them on their healthcare journey.

Leveraging technology, building trust and fueling behavior change

Before care avoidant individuals can be treated, they must be successfully identified and engaged—no easy feat. Consider a hypothetical scenario involving a person who has Type II diabetes.

In the past year, health insurance claims showed that this person experienced several emergency department and inpatient visits due to insulin shock. After each admission, the member received support from his health plan’s care team, yet the pattern persisted. Unknown to the hospital and health plan, the patient also suffered from acute pancreatitis—a key indicator for alcohol use disorder.

Advanced analytics can help health plans analyze member data such as past claims, diagnosis codes and prescription history so that they could flag the hypothetical Type II diabetes patient, for example, as having a high probability of substance abuse disorder and as a candidate for targeted outreach that could potentially improve the member’s health outcomes and lower costs.

But identifying “impactable” individuals—particularly before their conditions become chronic and costly—is just one step on a journey that also requires building a connection and trust.

Many people may be unaware that they are having issues with physical or behavioral health, but even if they are, may face myriad barriers to care and other factors that keep them from accessing the system. They may have systemic barriers to care, such as not being able to access the care they need because it is too far from home or unavailable during the times they are not working. Or they may be struggling with personal issues such as job loss or food insecurity, or even fear of care due to past negative experiences.

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Successfully engaging individuals starts by meeting them where they are, making them comfortable, and speaking to them based on what is important to them. Additionally, the process of engagement is not one-size-fits-all.

Some people may respond after one call, while others might require persistence and convincing. Some people might respond to calls while others may prefer texts or emails. This approach takes a holistic view of a person rather than simply focusing on their identified medical condition(s).

In addition to connecting members with the appropriate clinician, health plans will find it difficult to achieve behavior change without first helping them address barriers to care—whether it’s transportation to care, food scarcity or language issues, for example. But even when those issues are addressed, fueling lasting behavior change takes time. For some, less acute individuals it may be weeks, while for other who struggle with behavioral health and chronic conditions, it may take months.

By remaining focused on a person’s emotional, medical, and even social health, health plans and providers can better understand the primary issues impacting that person’s ability to engage in care. In doing so, they have an opportunity to establish the beginning of a relationship that is the basis for successfully engaging them for the long term.

Establishing trust through empathy and persistence are keys to lasting participation and providing value through a supportive and effective care plan delivers durable behavior change.

Curt Medeiros is president and chief operating officer of Ontrak Inc., a leading AI and technology-enabled healthcare company.